195850523-12-5-2025-29-AS-KLOZ-DPV5VJ-20251230191737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850523
Report Date: 12/05/2025
Date Signed: 12/05/2025 04:00:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2025 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20251126100943

FACILITY NAME:	PACIFIC SENIOR CARE		FACILITY NUMBER:	195850523
ADMINISTRATOR:	HAYRAPETYAN, VIKTORYA		FACILITY TYPE:	740
ADDRESS:	7731 ALDEA AVE		TELEPHONE:	(818) 516-8819
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 2	DATE:	12/05/2025
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Viktorya Hayrapetyan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not ensure that resident's medical needs were met in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced 10-day visit to investigate the allegation listed above. The LPA was greeted by staff. Staff contacted the Administrator Viktorya Hayrapetyan on the phone and LPA Urena explained the reason for the visit. LPA Urena, along with the staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

LPA Urena interviewed the Administrator and staff at approximately 10:55 a.m. and requested and reviewed records pertinent to the investigation. Additionally, the LPA interviewed the residents at approximately 11: 25 a.m. On 12/04/2025, LPA Urena interviewed the resident’s responsible party.

Continues on LIC 9099C ...page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20251126100943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFIC SENIOR CARE	FACILITY NUMBER: 195850523
	VISIT DATE: 12/05/2025

NARRATIVE

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Staff did not ensure that resident's medical needs were met in a timely manner.
On the allegation that Staff did not ensure that resident's medical needs were met in a timely manner, it is the concern of the Reporting party (RP) that R1 did not receive timely care when staff found blood in R1’s urine (on the lining of the incontinent pad). Furthermore, the RP stated that R1 refused to go to the hospital, and it was difficult for facility staff to obtain a urine culture.

To investigate the allegation, LPA Urena conducted record review, interviewed staff, administrator, R1 and R1’s responsible party. Record review indicated that R1 is alert and able to make their own decisions. The interview with the staff and the administrator revealed that they communicated immediately with R1’s responsible party about the stain on R1’s incontinent pad. The Administrator sent to R1’s responsible party a picture of the stain the staff noticed on the incontinent pad’s lining. The responsible party’s interview revealed that R1 is alert and makes their own decisions as much as possible. Furthermore, R1’s responsible party stated that when they received the picture of the lining of the incontinent pad, it appeared to be a brownish stain. The party responsible stated that it could have been due to slight dehydration and asked facility staff to provide and ask R1 to drink more water and see if it would resolve the occurrence of the brownish discharge. The party responsible asked the Home Health nurse to get a urine sample to be evaluated for blood, however, R1 refused; and when R1 was told that it would be best to get them to the hospital for the benefit of their health, R1 adamantly refused to go to the hospital. The party responsible added that the brownish discharge cleared the same day. The staff's interview revealed that R1's incontinent pad only had one occurrence when the brownish stain was visible. They checked R's incontinent pad 30 minuets after for at least a period of three hours and the incontinent pad was clear. LPA Urena attempted to interview R1, however the LPA was able to obtain only yes, and no answers due to R1’s speech; nevertheless, R1 was able to answer yes to questions related to the care R1 receives at the facility, as being good and denying having any physical concerns, and not wanting to go to the hospital.

Based on the information gathered through interviews, and record review, the facility staff followed regulations and protocol by informing R1’s responsible party about the concern and possible medical needs for R1 in a timely manner. The facility staff attempted to send R1 to the hospital to be assessed and R1 refused. Therefore, the allegation is deemed Unsubstantiated at this time.
Interview exit was conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC9099 (FAS) - (06/04)

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